<h1 class="title"><{t}>代理申请<{/t}></h1>
<form action="<{link ctl=pifa act=pfsave}>" enctype="multipart/form-data" method="post" name="pfsave" id='x-pifa-form'  class='pifaform'>
  <div class="FormWrap">
    <div class="division">
    <table width="100%" border="0" cellspacing="0" cellpadding="0" class="forform">
  <tr>
    <th><{t}>申请代理类型：<{/t}></th>
    <td><select name="pifatype">
      <option value="0" selected="selected">请选择申请类别</option>
     	
     	<option value="1">网店代理</option>
		<option value="2">实体店代理</option>
		<option value="4">网站代理</option>
		<option value="3">网店+实体店代理</option>
		<option value="5">网店+网站代理</option>
		<option value="6">网站+实体店代理</option>
		<option value="7">网站+网店+实体店代理</option>
        </select> <font color="red">*</font></td>
  </tr>
   <tr>
    <th>用户名：</th>
    <td><{input class="inputstyle" name="userid" type="hidden" required="true" value=$memberid }>
	<{input class="inputstyle" name="levelid" type="hidden" required="true" value=$level_id }>
	<{input class="inputstyle" name="user" type="hidden" required="true" value=$uname }>
	<{input disabled="disabled" class="inputstyle" name="username" type="text" required="true" value=$uname }></td>
  </tr>
  <tr>
    <th>申请人姓名：</th>
    <td>
	<{input class="inputstyle" name="shenfen_name" type="text" required="true" value=""  maxlength="50"  }> <font color="red">*</font>需与身份证上一致</td>
  </tr>
  <tr>
    <th>身份证上地址：</th>
    <td>
	<{input class="inputstyle" name="shenfen_addr" type="text" required="true" value="" maxlength="200" }> <font color="red">*</font>需与身份证上一致</td>
  </tr>
  <tr>
    <th>身份证号码：</th>
    <td>
	<{input class="inputstyle" name="shenfen_num" type="text" required="true" value="" maxlength="20" }> <font color="red">*</font>需与身份证上一致</td>
  </tr>
  <tr>
    <th>手机：</th>
    <td>
	<{input class="inputstyle" name="mobile" type="text" required="true" value=""  maxlength="15" }> <font color="red">*</font>请如实填写，代发货快递单上会写</td>
  </tr>
  <tr>
    <th>QQ：</th>
    <td>
	<{input class="inputstyle" name="qq" type="text" value="" maxlength="11" }> 请如实填写，代发货快递单上会写</td>
  </tr>
  
  <tr>
    <th>旺旺：</th>
    <td>
	<{input class="inputstyle" name="ww" type="text" value="" maxlength="30" }> 请如实填写，代发货快递单上会写</td>
  </tr>
  <tr>
    <th>网店用户名：</th>
    <td>
	<{input class="inputstyle" name="wangdian_id" type="text" value="" maxlength="100" }> 申请网店必填，请填写淘宝/拍拍等登陆名，网站填写ICP备案号</td>
  </tr>
  <tr>
    <th>网店网站地址：</th>
    <td>
	<{input class="inputstyle" name="wangdian_url" type="text" value="" maxlength="200" }> 申请网店或网站必填，多个地址请用|分开 </td>
  </tr>
   <tr>
    <th>实体店地址：</th>
    <td>
	<{input class="inputstyle" name="shiti_addr" type="text" value="" maxlength="200" }> 申请实体店必填</td>
  </tr>
   <tr style="display:none;">
    <th>身份证提交：</th>
    <td>
	<input type="file" name="sf_file" id="fileField" required="true"  /> 图片需清晰，jpg或gif格式，不超过500k</td>
  </tr>
  
  <tr>
    <th>实体店资料：</th>
    <td>
	<input type="file" name="yy_file" id="fileField" />	
	 申请实体店必须，营业执照或租赁合同，图片需清晰，jpg或gif格式，不超过500k</td>
  </tr>
  <tr>
    <th>从哪里得知我们：</th>
    <td>
	<input name="source" type="radio" value="bd" />百度
	<input name="source" type="radio" value="gl" />
	谷歌
	<input name="source" type="radio" value="pic" />
	图片广告
	<input name="source" type="radio" value="tb" />
	淘宝拍拍
	<input name="source" type="radio" value="bg" />
博客论坛
<input name="source" type="radio" value="fr" />
朋友介绍
	<input name="source" type="radio" value="ot" />其他   <font color="red">*</font></td>
  </tr>
 
   <tr>
    <th></th>
    <td>
	 <input type="checkbox" id="license" name="license" value="agree" checked="checked"/>
          我已阅读并同意 <a href="<{link ctl=page act=nvzhuangpifa}>" id="terms_error" class="lnk" target='_blank'><span class="FormText" id="terms_error_sym"><{t}>批发注册协议<{/t}></span></a>&nbsp;
		  请仔细阅读批发代理制度，由于未仔细阅读造成的问题我们概不负责。 </td>
  </tr>
  
  <tr>
    <th></th>
    <td><input type="submit" value="提交批发申请" /></td>
    </tr>
</table>
</div>


  </div>
</form> 

